Provider Demographics
NPI:1033253281
Name:CAVALLO, LISA ELLEN LEWIS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ELLEN LEWIS
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 NE FREMONT ST
Mailing Address - Street 2:#103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4437
Mailing Address - Country:US
Mailing Address - Phone:503-577-1385
Mailing Address - Fax:503-772-4776
Practice Address - Street 1:6221 NE FREMONT ST
Practice Address - Street 2:#103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4437
Practice Address - Country:US
Practice Address - Phone:503-577-1385
Practice Address - Fax:503-772-4776
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR018141041C0700X
WALW000050851041C0700X
MNPENDING1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01814OtherLICENSE